Provider Demographics
NPI:1891530226
Name:EVANS, JACLYN (PSYD)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 HUNTINGTON RD STE 199
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-1845
Mailing Address - Country:US
Mailing Address - Phone:706-546-8440
Mailing Address - Fax:
Practice Address - Street 1:485 HUNTINGTON RD STE 199
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-1845
Practice Address - Country:US
Practice Address - Phone:706-546-8440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4792103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical